Opponents of e-cigarettes claim that they are acting as a gateway to smoking for young people. However, 10 years of experience in the UK, US and Europe suggests that the opposite is true — that e-cigarettes may be reducing adolescent smoking rates.

Experimentation is a normal part of adolescence and many will try e-cigarettes, mostly out of curiosity. However, it is rare for non-smoking youth to become regular e-cigarette users. In the United Kingdom, less than 0.2 per cent of youth have never smoked “vape” regularly and there is no evidence of progression from vaping to smoking. Regular e-cigarette use is almost exclusively confined to young people who already smoke.

According to a recent comprehensive review by the respected Royal College of Physicians in the United Kingdom “e-cigarettes are being used almost exclusively as safer alternatives to smoked tobacco, by confirmed smokers who are trying to reduce harm to themselves or others from smoking, or to quit smoking completely”.

Another argument claimed to support the gateway effect is the idea that adolescents will become addicted to nicotine from using e-cigarettes and then progress to more dangerous tobacco products for a better nicotine hit. However, the great majority of adolescent e-cigarette users do not use nicotine. In the US, only 20 per cent of adolescent users used nicotine in 2015.

As e-cigarette use by adolescents is rising in many countries, adolescent smoking rates are falling faster than ever. For example, in the US, the National Youth Tobacco Surveys found that e-cigarette use by high school students rose from 1.5 per cent to 13.4 per cent from 2011 to 2014. However, conventional cigarette smoking fell from 15.8 per cent to an all-time low of 9.2 per cent during the same period, the most rapid rate of decline on record. If a gateway mechanism is operating, an increase in smoking rates would be expected.

It is quite possible that e-cigarettes are contributing to this rapid fall in adolescent smoking rates. Young people who experiment with e-cigarettes may otherwise have smoked if e-cigarettes were not available. Using an e-cigarette which may be more enjoyable and socially acceptable may prevent taking up the more harmful behaviour. It is obviously better for young people not to use e-cigarettes, but vaping is preferable to smoking and is at least 95 per cent safer.

Furthermore, there is evidence from the US that banning the sale of e-cigarettes to minors may increase adolescent smoking rates. Two large studies found that banning the sale of e-cigarettes to minors led to a significant increase in adolescent tobacco smoking rates compared to states without such bans.

In addition, some young people use e-cigarettes to help them quit smoking as do adult smokers. E-cigarette bans remove this treatment option altogether.

It is important to monitor electronic cigarette uptake for any potential risks. However, this new technology has the potential to save millions of lives and, according to the Royal College of Physicians, should be widely encouraged in the interests of public health.

The man whose small business selling e-cigarettes sparked a case which lead to the product being banned from sale in Western Australia has failed in his bid to overturn the landmark decision.

The prosecution of Vince van Heerden by the WA Health Department made WA the first jurisdiction in the world to outlaw the sale of e-cigarettes.

After a judge found it was illegal to sell e-cigarettes containing no nicotine, because they merely resemble a cigarette or cigar, the court imposed a fine of $1750.

An appeal against the decision was resolved today, with the Court of Appeal finding there were no errors of law in the original judgment.

Justice Robert Mazza commented it was not the court’s job to decide whether e-cigarettes were being sold for the purpose of helping smokers quit nicotine products.

“For the sake of clarity, this court should not be understood as having considered whether e-cigarettes are therapeutic and ought be available for sale. These are matters for Parliament,” he wrote.

Outside court, Mr van Heerden said he was shocked by the decision – which he claimed could send him bankrupt, and lead to other sellers facing legal action.

“I don’t think that selling them is a good idea from a legal point of view, from a moral point of view they’re heroes making a real difference to real people’s lives,” van Heerden said.

A test case against the Duncraig company selling e-cigarettes online, under the banner Heavenly Vapours, had brought about the landmark ruling.

The battery-powered devices do not burn tobacco but turn nicotine or fruit flavours into vapour which is inhaled and exhaled.

A magistrate originally ruled there was not enough evidence to prove the two types of e-cigarettes sold looked like real cigarettes.

But after an appeal from WA health bosses, the Supreme Court ruled selling e-cigarettes in WA should result in a trader being prosecuted.

The ruling provoked vociferous debate around the world, with proponents claiming e-cigarettes were an effective smoking cessation aid, while health campaigners fear the devices will encourage young people to smoke the real thing.

Australian Council on Smoking and Health president Mike Daube said the judgment was an important step in the continuing battle against smoking.

The Cancer Council said they welcomed today’s decision.

“There is growing concern about the possible harms of e-cigarette use, as well as the ways in which they are promoted. The evidence from overseas around the safety of e-cigarettes and their efficacy as a smoking cessation aid are not encouraging,” a spokeswoman said.

“The best thing smokers can do for their health is to quit, and there are good supports around.”

The world’s biggest tobacco companies are spending millions of dollars advertising e-cigarettes on UK television, as they seek to cash in on the growing trend.

Analysts at US investment bank Canaccord Genuity expect e-cigarettes to be the “most significant development in the history of the organised tobacco industry”. They estimate the global market will rise this year from £1.3 billion to £1.9 billion, and the potential for further growth is obvious: the existing tobacco business is worth £450 billion annually.

Traditional industry giants are moving in. Lorillard (the maker of American brands such as Newport and Kent) has bought Blu, an e-cigarette maker, for US$135m. British American Tobacco (BAT), the maker of Lucky Strike and Benson & Hedges, launched its own e-cigarette in the UK last July and Philip Morris International, the world’s biggest and most infamous tobacco company, is due to follow suit very soon.

If e-cigs are the future, then we have advertising regulations to thank, at least in part. The direct and indirect advertising of tobacco products in the press has been banned in the UK for a decade, while the last television commercial was shown almost 50 years ago. Two years ago, new laws required all supermarkets to hide cigarettes and related products from public view, and by 2015 all other business and smaller shops will also be obliged to comply.

The intention has been to eradicate images of tobacco from day-to-day experience, and to deter children from taking up the habit. Opinions tend to differ on the overall success of the bans but one thing is indisputable – fewer people now smoke in comparison to 30 years ago. The General Lifestyle Survey indicates 45% of adults smoked in 1974 compared with just 20% in 2011.

But the marketing of e-cigarettes is gathering pace. And at present there is no ruling to prevent their advertising, or any age limit on who can buy the products. For big tobacco this represents a chance to get creative, and maybe to gain some reflected cool. As the founder of one e-cigarette company points out, “the product shares certain characteristics with cigarettes, and you cannot be seen to promote smoking.”

The manufacturer E-lites, for instance, ran an advert last year featuring actor Mark Benton. Benton plays a father who nips outside for a cigarette and inadvertently misses out on his child’s first steps. The strapline: “What are you missing out on?” The obvious point is that the purchase of an e-cigarette means you never have to suffer the indignity and embarrassment of going outside to smoke again. Plus, you won’t miss out on life changing events.

More recently, a new e-cig known as the Vype was launched, with the strapline: “Experience the breakthrough”. The Vype advert does represent a breakthrough moment not just for manufacturer BAT, but for smokers everywhere. Featuring a young, good looking couple running through a dimly lit urban landscape, the 30 second ad ends with a still image of the product standing black and alone on a podium. We are meant to be infused with wonder and mystery and connect the attractiveness of the athletic couple with the sleek shiny Vype. If we didn’t know better this could be an ad for cologne.

Of course, companies want to appeal to the young, good looking and single. This is nothing new. But the “e” means such appeals can now be conducted overtly, and endorsements are on the increase. On its website, E-Lites features a range of celebrities puffing away, from Johnny Depp to Dappy from N-Dubz. Actor Stephen Dorff and former playboy model Jenny McCarthy front campaigns for bluCig.

But that’s not all. Welsh football team Merthyr Town now play in the “Cigg-e Stadium”, named after their new sponsor who has (not coincidentally) opened a shop in the town. Glasgow Celtic, with a massive international fanbase, have an “official partnership” with E-lites which effectively means vapour sticks can now be sold and consumed within its stadium.

Of course, such actions have not been welcomed by everyone. Criticising Celtic’s actions, Stewart Maxwell, MSP for West of Scotland, said, “The whole campaign to ban smoking in public places was about de-normalising smoking as an activity in public. This [deal] goes exactly in the opposite direction. It sends out entirely the wrong message to young people.”

E-cigarettes are increasingly popular in a number of countries including the UK, while in others such as Norway and Brazil they are banned altogether.

So amid all these differences in policy, what do we know and what don’t we know about e-cigarettes? And why, if they have the potential to save many of the lives taken by tobacco smoking each year are e-cigarettes currently one of the most contentious issues in public health research and policy?

Combustible simulation

E-cigarettes are battery operated devices that aim to simulate combustible cigarettes. They don’t contain tobacco but operate by heating nicotine and other chemicals into a vapour that is inhaled. Nicotine is the addictive substance in tobacco but we know that it is the many other chemicals in cigarettes that are responsible for smoking-related diseases.

Because electronic cigarettes deliver nicotine without the vast majority of these other chemicals, organisations such as the Medicines and Healthcare Products Regulatory Agency (MHRA) and the National Institute for Health and Care Excellence (NICE) have indicated that electronic cigarettes are less harmful than tobacco.

Questions, questions

Questions remain about the safety of e-cigarettes despite the fact that any risk that arises from using them is less than the risks of continuing to smoke normal cigarettes – and strong arguments have been made in favour of e-cigarettes from a health perspective because of this lower risk.

The first unanswered question is about the longer-term impact on health of inhaling nicotine and propylene glycol (a substance used in e-cigarettes that is also common in a range of other consumer products) deep into the lungs.

As e-cigarettes are largely unregulated, there are also questions about quality; variation in the chemicals in different cartridges, leaking cartridges and other problems such as the batteries in these devices. In other words, different companies can make very different products. There is some evidence that these technical safety issues are reducing as the quality of products on the market improves.

Another potential safety issue is around the vapour produced by e-cigarettes. There are still relatively few studies that have looked at the effects of exposure to vapour but one study examining vapour from 12 brands of e-cigarettes found a number of toxic substances, but these were at levels between nine to 450 times lower than in cigarette smoke.

Studies of the prevalence of use of e-cigarettes show that these products are being used predominantly by current smokers or recent quitters, either to stop smoking or to cut down. To date, there is limited evidence that people who don’t smoke are using e-cigarettes – just 0.5% of non-smokers in the UK in 2012, for example.

There are also unanswered questions about the extent to which children may be attracted to these products. In studies of e-cigarette use that include adolescents, including one that looked at use in Poland, most of those who had tried e-cigarettes were already current smokers. However, there is little doubt that some of the advertising of e-cigarettes may appeal to children, and recent research has highlighted the need for advertising controls in this area.

Getting the vapours about ‘vapers’

Users of e-cigarettes, particularly those who have successfully stopped smoking, are understandably enthusiastic about these products. There are an increasing number of vocal and well-organised “vaper” groups.

E-cigarette manufacturers are also a growing force in the economy of a number of countries, most notably China. However, health professionals and the public health community in particular have been less enthusiastic. This is due at least in part to some of the unanswered questions about e-cigarettes.

As Sally Davies, Britain’s chief medical officer, put it recently:

We do not yet know the harm that e-cigarettes can cause to adults let alone to children, but we do know they are not risk free.

In addition to the issues above, public health officials and others have argued that e-cigarettes could undermine smoke-free laws, such as bans on indoor smoking. They believe the e-cigarettes could confuse attempts to enforce laws when electronic products look like cigarettes, particularly from a distance.

An additional concern is that the increasing availability and popularity of the products may be driving smokers away from more evidence-based methods of trying to stop (like using a smoking cessation service or licensed stop smoking medication such as Nicotine Replacement Therapy) and that relapse to smoking might be more common as a result.

The tobacco industry

There is also considerable scepticism about the role of the tobacco industry in the e-cigarette market. A number of tobacco companies have now launched their own e-cigarette products (such as RJ Reynold’s VUSE) or have bought into existing e-cigarette companies (such as Lorillard’s purchase of Blu in 2012). New e-cigarette brands manufactured by tobacco companies are expected to continue to emerge in 2014.

This involvement has led some to wonder whether this is about finding safer alternatives to cigarettes or simply about creating a new market of “dual” users of combustible and e-cigarettes. It may also allow the tobacco industry to present a more “acceptable” image in the developed world while it continues to increase its profits from cigarettes in developing countries.

All these considerations mean that the use of e-cigarettes is currently one of the most contentious issues in public health research and policy. All the signs are that they represent a real opportunity to change the stubbornly persistent toll that tobacco takes on society. What the unintended consequences of their use will be, however, remains to be seen.

A New South Wales Greens MP has lit up an e-cigarette in State Parliament to prove a point about legal loopholes around the vapour devices.

Greens health spokesman Jeremy Buckingham caused a stir when he leaned back in his seat and started blowing puffs of vapour from the device during Upper House Question Time.

Government Whip Peter Phelps jumped to his feet to alert the Upper House President to Mr Buckingham’s behaviour.

“Mr Jeremy Buckingham is clearly smoking a vape cigarette in this house, more importantly, he’s done it with clear pre-meditation,” Dr Phelps said.

“It is an outrageous act against the decorum of this house.”

Mr Buckingham replied: “I’m not smoking.”

The President of the Upper House, Don Harwin, reprimanded Mr Buckingham for using props, but he was allowed to remain in the chamber.

Other MPs called out that it was a “stunt” and called Mr Buckingham a “media tart”.

The Government has introduced a bill to Parliament to ban the sale of e-cigarettes to minors, but the Greens and Labor say it does not go far enough.

Mr Buckingham said e-cigarettes should be dealt with under all the same laws covering tobacco and nicotine, including banning their use in non-smoking areas under the Smoke-Free Environment Act.

He said his actions in the house highlighted the double standard applied to e-cigarettes.

“I was trying to make a very important point today that under NSW law and the modest reforms of the Government, it is still legal in this state to vape in a preschool, on a bus, in a public space and even in the Parliament,” he said.

“I was making the point that this is a really serious health issue and the current reforms don’t go far enough in protecting the community.”